Prevention is better than cure. It is a cliché, but it is true. There are opportunities within public health policy to address the rising demand on the NHS and other public services. It is obvious to me that the future viability of the NHS depends on a coordinated approach to public health, nationally and locally.

Secondary care specialists and public health doctors are crucial, providing specialist knowledge and expertise on clinical issues and the health of the population.

Giving local authorities greater public health responsibility does give us an opportunity to tackle the broader social determinants of health, such as housing and air quality. However, there is a risk that there will be a dislocation of ‘medical’ and ‘public’ health.

To avoid this, we need to take an integrated approach. I believe public health specialists should also sit on the board of all Clinical Commissioning Groups (CCGs) and the NHS Commissioning Board. Reciprocally, hospital doctors should be represented on Health and Wellbeing Boards, which will be based in local authorities. This will help to develop and strengthen their links with the NHS.

I have been calling for the statutory registration of public health professionals. This will help to ensure that directors of public health, and public health staff that support them, have the skills and experience needed for this expert and specialised job. I would encourage the government to give the Health Professions Council the role of regulating public health professionals.

I am extremely sceptical about the Responsibility Deal’s ability to resolve major public health issues, such as obesity and alcohol. The RCP, along with five other health organisations, declined an invitation to sign up to the alcohol responsibility deal because of serious reservations about the proposed alcohol pledges.

There is an inherent conflict of interest when industry drives public health policy, and in particular the alcohol deal only set out a number of aspirational, unenforceable and weak pledges. The ‘carrot’ approach of voluntary agreements with industry is unfortunately not enough to prompt healthy behaviours; it needs to be complemented by the ‘stick’ approach of legislative solutions where necessary.

Recently, the Health Select Committee voiced concerns about the independence of Public Health England (PHE) and I must say that I echo its unease. PHE must be authoritative, independent and able to hold the government to account. To do this, PHE must be visibly and operationally independent of Ministers. Locally, directors of public health must have sufficient influence, and therefore should be appointed to chief officer level within local authorities. They should have the authority to determine the best way of distributing the local authority public health budget.

There are opportunities within public health policy to address the rising demand on the NHS and other public services; they must not be missed. The government must use all available levers to improve and protect the health of the population, otherwise the NHS will be swamped.

At this moment in time thousands of public health nurses are left in limbo, seeing changes on the ground but with no real news or updates from the people making them. The RCN is concerned that significant changes are being made to public health staff, in the absence of the guidance promised by the Government.

In the Update and Way Forward policy statement in the middle of July, the Department of Health committed to producing updates on the five key areas of reform during the autumn. Just to be clear, this set of work is an overhaul to the way we tackle public health issues, it isn’t a list of mere tweaks and small changes. In case you aren’t aware, the five areas are:

Public health outcomes framework

Public Health England operating model

Public health in local government and the director of public health

Public health funding including shadow local authority allocations for 2012-13

Public health workforce strategy consultation

Here at the RCN, we understand that the shadow budget allocations and consultation on the workforce strategy may not be released until 2012. What’s more, there is no sign of updates on the remaining three areas as 2011 draws to a close; meanwhile, RCN members are being affected right now.

Back in early November, the RCN welcomed the Health Select Committee’s report on Public Health; it recommended that uncertainty around the future structure and focus of public health in England must be resolved as quickly as possible. You can understand why we’re now concerned.

At the time, the RCN Chief Executive & General Secretary, Dr Peter Carter, commented that “Many public health nurses are currently in a state of limbo as they wait to see how proposed transfers to local authorities will affect their jobs and the services they offer to the public.”

While we understand that the issues requiring consideration are significant, nursing staff need clarity and deserve answers. On behalf of public health staff everywhere, I very much hope that 2012 provides us with more information, not only for the benefit of staff, but the patients who are so dependent on the care that they provide.

by Professor Allyson Pollock, professor of public health research and policy at Queen Mary, University of London

The Health and Social Care Bill 2011 represents the biggest threat to public health for 60 years and it is time for the public health community to stand up and say so.

Deliberately conceived as an ‘Abdication and Abolition Bill’, the proposed legislation would sever the duty of the Secretary of State to secure and provide comprehensive healthcare throughout England.

Entitlements to health care are to be abandoned in order that a consumer market can be substituted for a needs-based system and, in David Cameron’s words, the NHS turned into a “fantastic business for Britain”.

As these briefings to the House of Lords show, the Bill will destroy the public health foundations of comprehensive healthcare and the ability to gather information and monitor inequalities.

Geographic administrative units – the hallmarks of the NHS – are to be abolished. Whilst commissioner populations will be made up from GP registrations, GP boundaries are being dissolved. Patient enrolment and disenrollment will lead to unstable denominators and render fair service allocation and planning impossible.

No-one will have ultimate responsibility for ensuring everybody in a geographic area gets access to a GP. Above all, the ability to monitor equity of access within a comprehensive system will be undermined by lack of data and local variations in entitlement.

Public health will be shunted out to local authorities but the resources, functions and services that will go with it are not defined. It is even impossible to tell the populations for which it will be responsible.

Local authorities and clinical commissioning groups will have enormous freedom to decide what they will and won’t provide and the boundaries between chargeable and non-chargeable services will be blurred and subject to local eligibility criteria.

In place of equity will be service and patient selection by commissioners and service providers intent on managing the financial risks of the marketplace. Commissioners will be allowed to outsource their functions to healthcare companies that specialize in these techniques.

The marketisation of healthcare will lead to the denial of care on a scale not seen in England since pre-war days.

At a minimum the Bill must be amended so as to restore all the Secretary of State’s duties and functions and the structures of a national public health service.

The results of our latest member survey show despair, uncertainty and distress about the NHS reforms. We share members’ anger and frustration, reflected in feedback from local boards and committees. The results articulate the possibility of a wholesale departure from the specialty and major risks to the protection and improvement of the public’s health and the services they receive.

Wordcloud: Adjusted responses (phrases/themed/categorised), from the first 200 responses in the survey (maximum 50 phrases)

As peers continue to debate the reforms, attitudes of public health professionals, and FPH’s leadership, are hardening. Faced with a government which does not seem to value professionalism or standards, it is essential that we continue to fight for the standards, accreditation and regulation of public health. No-one else will – and our partners in the public health national lobby agree with our stance.

Members have broadly supported this direction of travel – until now. The ignorance and disregard in high places of what public health is and has done over 40 years in the NHS is alarming. FPH continues to hold a strong expectation for:
• An independent and robust Public Health England;
• A coherent career and training structure for public health professionals;
• Protection of terms and conditions of staff;
• Directors of public health reporting to chief executives of councils,
• Clarity in the size and applications of the ring fenced budget and
• Professional regulation for all public health specialists.

These issues were met with welcome support in the House of Lords committee stage. However, a substantial cadre of our members believe that the public health community must campaign more explicitly against the likely negative health impacts if the reforms go through unchecked.

The Secretary of State has had a duty to ‘provide and secure’ the NHS since it began. NHS planning has historically relied on regulations and guidance, not legislation. This enables the NHS to move forward if the Secretary of State is in charge. If not, every line of the Health Bill becomes crucial.

Hard-pressed local authorities will only do what they must by law CCGs also will only do what they are required to do in law. The health system becomes a giant free-for-all; everyone doing the least possible, or the most lucrative and pocketing taxpayers’ cash. Some services may be deemed ‘bad business decisions’ and not be provided.

Where will these be without the Secretary of State’s duty to secure? This is a health insurance versus public health model. It calls into question the ideal of public service with which most of our members entered the NHS. Everyone in public health and health service users should be concerned about that.

As part of this debate, we have invited a range of organisations to contribute to this blog. It remains open for members’ comments and more formal critiques. We look forward to your contributions here and through your local board members and FLACS.

Disclaimer

The aim of this blog is to encourage discussion and debate on public health issues. The views expressed here are the personal views of authors, and the content does not reflect the official position of the Faculty of Public Health. However, discussion generated here may be used to influence the development of organisational policy.